Health inspection·January 24, 2024

F 0684 the MD revealed, no orders for blood sugar monitoring. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's Order Summary Report dated 01/23/24 revealed, check blood sugars before meals and at bedtime entered on 01/18/24 and started on 01/18/24 at 09:00 AM, over 12 hours after admission to the facility. Residents Affected - Few Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM. - 311 mg/dL on 01/18/24 01:11 PM documented by LVN B. - 207 mg/dL on 01/18/24 05:52 PM documented by LVN D. - 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D. An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted she did not have her blood sugar checked even though she ate meals. Resident #1 said the day after she admitted was the first day she had her blood sugar check but she denied any symptoms or side effects of high blood sure. In an interview on 01/23/24 at 02:35 PM, the DON said when a resident arrives at the facility, they were immediately placed in a room with the staff assisting the paramedics. She said the admitting nurse then completed a head-to-toe assessment, collected vitals (including BS for diabetics) reconciled medications and then contacted the physician to approve all medications and care records. The DON said per the EMR Resident #1 admitted to the facility at 02:50 PM and LVN A completed Resident #1's admission assessment after she arrived at her shift which usually starts between 4 and 5. In an interview on 01/23/24 at 05:11 PM, LVN A said she had been in her role as the admission nurse for the past 3 years. She said when a resident admitted to the facility the nurse who received them was responsible for verifying the residents' medications/orders with the admitting physician and checking vitals which included blood sugar checks. LVN A said she saw Resident #1 when she arrived at her evening shift, the resident was primarily Spanish speaking and arrived at the facility with family. She said she was not the nurse who received the resident, and it was not her responsibility to enter the resident into the system, complete the admitting assessment or check the resident's vitals. LVN A said it was the responsibility of the actual nurse who admitted the resident and the unit manager to ensure all orders were entered and vitals like BS were checked. LVN A said even though she did not actually assess the resident or reconcile the medications/order with the physician, she helped enter the resident's admission assessment and orders a little after six. She said she did not know why she did not enter Resident #1's BS monitoring orders and failure to check blood sugars in a diabetic could place the resident at risk for unidentified hypo or hyperglycemia (low and high blood sugars). In an interview on 01/24/24 at 09:35 AM, the DON said the nurse who received Resident #1 was responsible for checking vitals, which included blood sugars in diabetics, going over the medications and orders with the physician and then entering the orders in the system. The DON said after reviewing the chart, LVN B was the nurse who received Resident #1 but since the resident arrived during a shift change his unit manager should have been responsible for entering the resident's orders into the system. She said she could not determine which nurse reconciled the medications and orders with the physician from the records provided. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 01/24/24 at 10:01 AM, LVN B said when resident arrived at the facility the admitting nurse was whoever received the resident. He said the admitting nurse was responsible for ensuring that the resident was comfortable, educated about the facility and collecting vitals, reconciling medications with the physician and then entering orders. LVN B said upon admission, the admitting staff must check a diabetic resident's blood sugars immediately to establish their baseline if they did not receive BS records from the discharging facility. He said facility's policy required all new admissions that arrived after 02:00 PM would be given to the unit manager and Unit Manager A was responsible for admitting Resident #1. LVN B said LVN A was the facility admission nurse, and her shift usually began between 04:00-05:00 PM and she would complete admissions of residents who arrived during her shift. In an interview on 01/24/24 at 11:42 AM, Unit Manager A said she was the 2nd floor unit manager, and her shift was from 08:30- 05:00 PM. She said when a resident admitted into the facility, the admitting nurse was responsible for greeting the resident, reconciling medications, verifying orders with the physician and then entering the orders. Unit Manager A said all diabetic residents should have admitting orders to check their blood glucose and lab orders for A1c. She said failure to enter BS orders and check blood sugar upon admission could place the resident at risk for unknown low/high BS and a result in the failure to treat these uncontrolled blood sugars. Unit Manager A said after reviewing the EMR, Resident #1's order entry was her responsibility but LVN B, the admitting nurse, was responsible for checking the resident's BS since it was part of the vitals collected. Unit Manager A said she did not remember processing Resident #1's admission but due to the time the resident arrived it was her responsibility but she was not informed or provided any communication that she had to complete the resident's admission so that was why LVN A completed the admissions assessment and entered the medication orders. Unit Manager A said she could not remember any details regarding Resident #1's admissions. In an interview on 01/24/24 at 12:40 PM, the DON said when Resident #1 admitted to the facility LVN B (the admitting nurse) was responsible for entering orders for BS monitoring and he should have checked the resident's BS upon admission. She said the DON was ultimately responsible for ensuring admissions orders are entered correctly but the responsibility is delegated to the unit managers. The DON said failure enter orders and monitor blood sugars in diabetics could result in a worsening of prognosis as well as hypo and hyperglycemia. In an interview on 01/24/24 at 12:54 PM, LVN B said he did not check Resident #1's blood sugars upon admission or enter her blood sugar monitoring orders and he did not know whose responsibility it was since the resident arrived during a change of shift. An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. Record review of the facility policy titled Blood Glucose Management revised 10/2016 revealed, program overview- charge nurses will provide blood glucose management per Health Care Provider's order. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. - The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL. This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization. Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia. Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital. Record review of Resident #1's Pre-admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels. Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM. Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed, - Cefdinir (an antibiotic) 300 mg- 1 capsule by mouth every 12 hours for 5 days, with a start date of 01/18/24. - Metformin (an oral antidiabetic) 1000 mg- 1 tablet by mouth two times a day for diabetes with a start date of 01/18/24. - Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24. - Tresiba Insulin- Inject 30 units under the skin every 12 hours for type 2 diabetes with a start date of 01/17/24. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm - Gabapentin 300 mg- 1 Capsule by mouth two times a day for nerve pain with a start date of 01/18/24 at 09:00 AM. Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM. Residents Affected - Few - 311 mg/dL on 01/18/24 01:11 PM documented by LVN B. - 207 mg/dL on 01/18/24 05:52 PM documented by LVN D. - 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D. Record review of Resident #1's 01/17/24 MAR revealed, - Cefdinir 300 mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Gabapentin 300mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Metformin 1000mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Tresiba Insulin was not administered on 01/17/24 even though it was scheduled for 09:00 PM for reasons not documented. - Insulin Lispro was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed, - Metformin 1000 mg was first administered on 01/18/24 at 11:26 AM. - Cefdinir 300 mg was first administered on 01/18/24 at 11:26 AM. - Insulin Lispro was first administered on 01/18/24 at 01:11 PM. - Tresiba Insulin was first administered on 01/18/24 at 01:11 PM. - Gabapentin was first administered on 01/18/24 at 11:26 AM. Record review of the facility automated dispensing machine inventory list presented on 01/23/24 revealed, - the facility had 10 capsules of Cefdinir 300 mg capsules on hand for emergency dispensing or newly admitted residents. - the facility had 6 capsules of Gabapentin 300 mg capsules on hand for emergency dispensing or (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing (X3) DATE SURVEY COMPLETED A. Building 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 newly admitted residents. Level of Harm - Minimal harm or potential for actual harm - the facility did not have Tresiba or Insulin Lispro on hand for emergency dispensing or newly admitted residents. Residents Affected - Few Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, - Tresiba Insulin was first delivered to the facility on [DATE] at 11:59 PM. - Metformin 1000mg was first delivered to the facility on [DATE] at 11:59 PM. - Gabapentin 300 mg capsules was first delivered to the facility on [DATE] at 11:59 PM. - Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send. In an interview on 01/23/24 at 01:23 PM, the ADON said the facility received 3 different pharmacy deliveries. She said the pharmacy delivered medications to the facility in the early morning, mid-day and at night but there was always an option for a STAT delivery to be made within 2 hours for any urgent medications that the facility did not have in their automated dispensing system. The ADON said the facility did not have any insulin on hand for newly admitted or emergency medication orders. An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted (01/17/24) she did not her medications. Resident #1 said she did not receive her antibiotic, Gabapentin and antidiabetic medications (Metformin and Insulins) on 01/17/24 but she did not suffer from any pain or signs/symptoms of uncontrolled blood sugars. In an interview on 01/23/24 at 02:35 PM, the DON said per the EMR, Resident #1 admitted to the facility at 02:50 PM but her medication orders were not entered until after 06:00 PM. She said when a resident arrived at the facility their medication orders should be started immediately to avoid any missing doses based on the hospital discharge medication list. The DON said the facility had an automated dispensing system that could provide initial doses of medications for new admissions and any unavailable medications like insulin could be acquired within 2 hours from the pharmacy through a STAT order. She said if the pharmacy was unable to deliver the medication immediately, the resident's provider should be contacted for an alternative regimen and all medication issues should be documented in the resident's chart. The DON said failure to administer medications immediately upon admission could result in increased blood sugar, increased pain, as well as worsening of infection and hospitalization. In an interview on 01/23/24 at 05:11 PM, LVN A said she has been in her role as the admission nurse for the past 3 years. She said when a resident arrived at the facility the nurse should reconcile the medications against the discharging facility medication lists and medications should be administered based on the last administered dose. LVN A said since Resident #1 arrived at 02:50 PM she should have received her first dose of medications starting that evening and did not know why she entered Resident #1's medications to start the next morning. She said the facility had an automated dispensing system that had the necessary oral medications on hand and the insulin could have been received (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few within 2 hours through a STAT order from the pharmacy. LVN A said she did not know why she did not get the medication from the automated dispensing system, or from the pharmacy and she did not know why she did not document the issue in the resident's progress notes. LVN A said the doctor did not give her approval to delay the start of Resident #1's medications and failure to administer medications immediately upon admission could place residents at risk for uncontrolled health conditions, uncontrolled blood sugars, uncontrolled pain and hospitalization. She said Resident #1 should have received her first dose of medication the night she arrived at the facility. In an interview on 01/24/24 at 12:40 PM, the DON said she was ultimately responsible for ensuring medications were started immediately upon admissions and administered as ordered but that responsibility was delegated to the managers who complete next day audits. She said to her knowledge no one had noticed that Resident #1 was not administered medications upon admissions and her first doses were administered late in the afternoon the next day. The DON said Resident #1, the resident's family as well as her doctor was notified of the missed medications and the resident reported no side effects and the physician did not give any new orders. An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. Record review of LVN A's Charge Nurse Orientation Checklist-Skilled Nursing signed on 09/01/20 revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. Record review of the facility policy titled Reconciliation of Medications od Admission/re-admission and Monthly Orders revised 03/2019 revealed, policy overview- the charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care, for the purpose of providing an accurate and current medication regimen. I(B)- Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process by: identifying the medications the resident needs and administering without interruption, the correct dosages and routes. Record review of the facility policy titled Receipt of Interim/Stat/Emergency Deliveries revised 01/01/22 revealed, 1- facility should immediately notify pharmacy when facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions: 2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or 2.2 For Pharmacy delivery by contract courier, or 2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #1) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document administration of medication to Resident #1 by documenting administration of Insulin Lispro that was not in the facility and did not occur, This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia. Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital. Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed, - Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24. Record review of Resident #1's 01/17/24 MAR revealed, - Insulin Lispro was administered on of 01/18/24 for scheduled doses at 09:00 AM and 01:00 by LVN B. Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed, - Insulin Lispro was first administered on 01/18/24 at 01:11 PM for the doses scheduled at both 09:00 AM and 01:00 PM. Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, - Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675834 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookdale Galleria 2929 Post Oak Blvd Houston, TX 77056 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send. In observation on 01/24/24 at 12:14 PM, inventory of the nursing cart with LVN B revealed, an Insulin Lispro pen labeled for Resident #1 with the facility open date of 01/19/24 on both the pen and on the pharmacy label. Inspection of the 2nd floor medication room with LVN B revealed, no other insulin pens for Resident #1 in the fridge. In an interview on 01/24/24 at 12:40 PM, the DON said staff were expected to document accurately and timely and any discrepancies should be documented in the progress notes. She said Resident #1's insulin arrived on 01/18/24 at 11:59 PM and based on the residents EMR it was not possible for LVN B to administer the 09:00 AM and 01:00 PM scheduled doses of Insulin Lispro to Resident #1 on 01/18/24 at 01:11 PM because the medication was not available in the pharmacy at that time and the facility did not have any insulin on-hand for emergency dispensing. The DON said failure to document accurately placed residents at risk for inaccurate medical records and unidentified missed doses. In an interview on 01/24/24 at 12:54 PM, LVN B said to his knowledge Resident #1 did not have any insulin missing and he did not remember administering Resident #1's insulin late at 01:11 PM on 01/18/24 even though it was the documented time on the MAR. LVN B said the only insulin pen Resident #1 had was the pen observed in the nursing cart with an open dated of 01/19/24 and he could not explain where the insulin he documented as administered came from since the pen had not arrived at the facility at the documented time of administration. When asked about the requirement of accurate and timely documentation, LVN B could not provide an answer. He said he did not remember any specifics about Resident #1's Insulin Lispro pen and medication administration time and when asked how he documented the administration of medication that was not available he said I also want to know what happened with the medication and the documentation. He could not provide any details regarding the discrepancy between the documentation and the unavailability of the medication. Record review of LVN B's Charge Nurse Orientation Checklist-Skilled Nursing signed on 04/24/22 by the ADON revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. Record review of the facility policy titled Medication Administration revised 12/2020 revealed, after administering/observation of the client taking the medication the staff must sign for the scheduled assistance time and date for medications and if applicable, the associate should document the refusal or reason for not administering medication as ordered. Record review of the facility policy titled Documentation for Skilled Services revised 05/2023 revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times. Record review of the facility provided Skilled Documentation Guide with no revision date revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675834 If continuation sheet Page 9 of 9